Diagnosis, Treatment & Prognosis of Disc

Associated Wobbler Syndrome in Dogs

By Dr. Filippo Adamo, DVM, Dipl. ECVN, Veterinary Neurology Specialist
President Bay Area VNC (Veterinary Neurology Neurosurgery Consulting)
208 Santa Clara Way, San Mateo, California, USA 944033 (608)334-3713
[email protected] www.bayareavnc.com
Dr. Adamo is European
Board Certified
Veterinary Neurologist
and Neurosurgeon.
During the last 20 years,
he built up his
neurological experience
in both academia and
private practice in both
Europe and USA. Dr.
Adamo has been a Board
Certified Neurologist
since 1997. Prior to
moving to California, Dr.
Adamo served from 2002
to 2007 as Clinical
Assistant Professor in
Neurology at the School
of Veterinary Medicine, University of Wisconsin. He then moved
with his family to California where he served as Chief of
Neurology at the Bay Area Veterinary Specialists in San Leandro
until July 2009. As a chief of neurology at the University of
Wisconsin, he developed many years of experiences in research
and clinical neurology/ neurosurgery. Dr. Adamo developed an
alternative cyclosporine medical treatment for Granulomatous
meningoencephalomyelitis (GME) in dogs, designed a frameless
guided stereotactic CT guided brain biopsy, investigated
alternative medical therapy for brain meningioma in dogs and
cats, and developed and tested the first artificial disc for the
canine cervical spine. He has lectured and published extensively
in the United States and Europe. His main areas of interest are
brain inflammatory diseases, and brain and cervical spinal
surgery. When not spending time with his son, and their dog
(Pancio), Dr. Adamo enjoys playing Brazilian rhythm music and
Aikido.
Introduction
Wobbler syndrome in dogs refers to a collection of disorders of
the cervical vertebrae and intervertebral discs of large breed
dogs resulting in cervical canal stenosis and spinal cord
compression. All these different clinical entities result in the
same clinical signs, mainly characterized by a typical wobbling
gait (predominantly affecting the hind limbs), paresis and
cervical pain. The most typical and predominant syndrome
is the disc associated Wobbler syndrome (DAWS). DAWS,
predominantly affects middle to older age, large-breed
nonchondrodystrophoid dogs, particularly Doberman
Pinschers. Doberman Pinschers may be predisposed to
clinical cervical spinal cord compression by congenital relative
vertebral canal stenosis with a loss of reserve space. Many
other breeds have also been reported as being affected by this
condition (including small dogs), and in one study of 90 dogs,
where Doberman Pinschers were excluded, thirty-two breeds
were represented, of which Labrador retrievers (13),
Dalmatians (13) and Rottweilers (12) were the most commonly
affected. The main factor in DAWS is the underlying chronic
disc degenerative disease, which is also common in
Rottweilers. The C5-C6 and C6-C7 disc spaces are most
commonly affected, with lesion in both interpaces present in
about 20% of affected dogs.
Pathogenesis
Although the pathogenesis of DAWS is not well understood, it is
thought to be multifactorial including primary developmental
abnormalities and secondary degenerative changes that lead to
vertebral canal stenosis and spinal cord compression. Chronic
degenerative disc disease seems to be such an important factor
that the term "DAWS" has been suggested. Spinal cord
compression in DAWS is often dynamic and secondary to a
combination of degenerative disc diseases (leading to protrusion
of the intervertebral disc) and the relative redundancy, relative
hypertrophy, or "in folding" of the ligamentous structures (dorsal
longitudinal ligament, dorsal annulus, interarcuate ligament and
joint capsule) because of collapse of the disc space. The relative
redundancy of the dorsal longitudinal ligament and the dorsal
annulus results more often in ventrally located spinal cord
compression. The relative redundancy of the interarcuate
ligaments and joint capsules may result in dorsally located spinal
cord compression, with or without osteoarthrosis of the
overloaded facets, or articular processes. Simultaneous
narrowing of the intervertebral foramina because of disc space
collapse may cause neurovascular compression at the foramina.
Generally in-traction responsive lesion, the dorsal and/or ventral
spinal cord compression may be reduced by the application of
linear traction to the cervical spine which re-establishes disc
width, flattens the relatively redundant soft tissue structures, and
opens the narrowed foramina. In most dogs, 2-3 mm of
distraction restors a normal disc width of 4-6 mm.
Diagnosis - Clinical signs
Animal affected with DAWS are usually 4-8 years of age. The
most common presentation of DAWS is ataxia (lack of gait
coordination), which is most severe in the pelvic limbs, cervical
pain and low carriage of the head. Clinical signs may range from
only cervical pain (5-10% of patients) to paralysis. The owners
commonly report a gradual onset, although the symptoms can
sometimes occur or exacerbate more acutely. A slowly
progressing hind limbs ataxia and/or paresis of the pelvic limbs is
usually noted. Progression to thoracic limbs involvement with
short stilted gait can also occur. A broad-based stance can be
noticed in the hind limbs. Affected dogs often show a
characteristic "disconnected" gait, where the thoracic limbs seem
to advance at different rate. The disease is usually chronic
progressive if left untreated. Prognosis is usually worse for dogs
with chronic clinical signs and severe tetraparetics.
Survey radiography
Survey radiography may be suggestive of DAWS but they are not
conclusive. They are used as preliminary screening before more
specific advanced imaging diagnostic techniques such as
myelography, computed tomography (CT) and magnetic
resonance imaging (MRI). Survey radiographies are useful to rule
out potential other causes of cervical diseases such as vertebral
fractures, subluxations, vertebral tumor, and discospondylitis.
General anesthesia or sedation is necessary to obtain correct
positioning of the dog. Mild deformity of the cervical vertebral
Dr. Filippo Adamo & his dog Pancio
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Lateral myelography of a 5-year old Doberman. Severe narrowing of the
intervertebral disc space between C6-C7. Malformation of the cranioventral border of
C7 is evident. Severe extradural spinal cord compression is noted (a). The severity of
the compressive lesion reduces remarkably in size with traction (b)
body and spondylosis deformans ventral to the intervertebral
space may be seen, and narrowing of the intervertebral disc
space is frequently seen. However, changes on survey
radiographs do not always correlate with spinal cord
compression. Some dogs with severe radiographic
abnormalities will show no spinal cord compression on
myelography or MRI and demonstrate no clinical signs. Survey
radiographs may be normal in some dogs with DAWS.
Advance Imaging Diagnostic (Myelography, CT and MRI)
Diagnosis of DAWS can be made by myelography with traction
views (stress myelography) or MRI. In DAWS the extent of
cord compression can vary with flexion, extension and linear
traction (distraction).
Owing to the risk of neurologic deterioration after these
cervical manipulations during general anesthesia, only linear
traction myelography or linear traction MRI views continue to
be routinely used. Cross sectional computed tomography (CT)
combined with myelography may also help to better visualize
spinal cord compression and spinal cord atrophy.
Recently, MRI was shown to be more accurate and more
informative than cervical myelography or CT-myelography.
MRI better defines the site, severity and nature of spinal cord
compression, and in allows visualization and characterization
of intraparenchymal spinal lesions. Association between
spinal cord MRI findings and histologic abnormalities has been
documented. The possible complications that can be caused
by myelography are not caused by the MRI, because this
technique does not require the injection of a contrast medium
into the subarachnoid space.
Static versus Dynamic lesion
The concept of static and dynamic lesions was first established
in 1982 and determination of the "dynamic" or "traction
responsive" feature, in contrast to "static" lesions (such as
extruded disc material, malformed facets, or deformed
vertebral arches), has been suggested as being essential for
the most appropriate operative technique. However, distinction
between dynamic and static lesions is currently unclear,
subjective, and dependent on personal opinion. However, it
appears that 20% of the
dog's weight is enough to
produce sufficient traction,
and it is unnecessary to
use traction forces higher
then 25% of the patient's
weight. Generally,
in-traction responsive
lesion, the dorsal and/or
ventral spinal cord
compression may be
reduced by the application
of linear traction to the
cervical spine which
re-establishes disc width,
flattens the relatively
redundant soft tissue
structures, and opens the
narrowed foramina. In most
dogs, 2-3 mm of distraction
restors a normal disc width
of 4-6 mm.
Treatment - Medical treatment
Medical treatment with activity restriction and corticosteroids may
be indicated in a normal dog with a first episode of neurologic
deficits following minor trauma; otherwise, surgery is the
treatment of choice. Conservatively treated dogs should have
restricted activity for at least two months. In one study, where
medical treatment was used, a successful outcome was achieved
in 45% of the patients. In the same study, in 85 % of the dogs in
which euthanasia was performed because of progression of
DAWS, was carried out in the first year of diagnosis. This study
concluded that conservative treatment for DAWS is associated
with a guarded prognosis. In another study, that compared
medical versus surgical treatment, it was found that 81% of dogs
surgically treated (via ventral slot, dorsal laminectomy or
distraction fusion) improved, compared to the 54% of dogs that
improved with medical treatment.
Surgical treatment
There are many surgical techniques described to treat DAWS,
which can be broadly divided into two categories: direct access
decompressive surgeries and distraction-stabilization surgeries.
Direct access decompressive surgeries involve removal of the
hypertrophied annulus fibrosus and dorsal longitudinal ligament
via ventral slot or dorsal decompression via dorsal laminectomy.
Dorsal laminectomy: dorsal decompression is usually
recommended for dogs with single dorsal lesions who do not
respond to traction as well as do patients with multiple dorsal
lesions. The major disadvantages are that extensive soft tissue
dissection is needed, the ventrally located disk material cannot
be removed, and there is significant, short term morbidity with
deterioration of neurological status, which can cause
considerable nursing problems in giant-breed dogs. In one study,
fourteen of twenty dogs undergoing dorsal laminectomy had
immediate decline in neurologic grade. Although dorsal
laminectomy should not cause domino lesions, recurrence of
clinical signs has been reported in 10% of dogs secondary to
restrictive fibrosis.
Ventral slot: ventral decompression alone, can be technically
challenging and exacerbates instability, particularly in extension.
Ventral decompression may also result in further collapse of the
disc space and exacerbates spinal cord compression with
additional infolding of the legamentous structures and joint
capsules. Bleeding from the venous plexus is also a major
complication of ventral decompression, which in rare cases
requires a blood transfusion. In over 20% of patients treated with
ventral slot alone, failure to respond to treatment was associated
with inadequate removal of disc material, which increased spinal
cord compression as the intervertebral space collapsed at the
T2-weighted sagittal MR1 of a 4- year old Rottweiler
affected by DAWS. At the level of C2-C3, there is a
complete loss of the hyperintense (white) CSF signal
around the spinal cord with subsequent spinal cord
compression. At this level, there is complete disc
degeneration characterized as a total of
hyperintensity of the disc that now appear grey
(arrow), in contract to a normal and healthy disc
(dotted arrow). This dog was surgically teated by
ventral slot. His neurological status slightly
deteriorated 2 weeks post-operatively, most likely
secondary to a further intervertebral disc space
collapse. The dog progressively improved over the
following 6 months.
Tranverse plane of CT-myelography
of a 6-year old mix-breed dog at the level
of C5-C6. The subarachnoid space is
filled with a radiolucent contrast
material (white). The spinal cord (dark)
is delineated by the surrounding
subarachnoid space. A ventral spinal
cord compression secondary to the
protrusion of the intervertebral disc
with the associated dorsal ligamentous
structures are evident. The spinal cord
lost its normal rounded appearance and
is markedly distorted.
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treated site. Collapse of the intervertebral space can also
compress the nerve roots in the intervertebral foramen, which
in turn may cause cervical hyperesthesia and focal spinal cord
ischemia. Ventral decompression alone has also been
associated with vertebral subluxation. In the long term this
technique seems to be clinically effective and instability, if
present, may be alleviated because after ventral
decompression many of these interspaces will fuse, even
without cancellous autografting.
Distraction-stabilization: distraction-stabilization-fusion
techniques distract the vertebrae to stretch the hypertrophied
tissue and relieve spinal cord compression; the vertebrae are
then stabilized with appropriate implants and fusion is
promoted with bone autografts (cancellous, cortical or
corticocancellous) and cancellous bone allograft. Various
techniques have been used to maintain distraction and/or graft
retention to allow for bony fusion of the affected interspace.
These include screws and washers, smooth pins, threaded
pins or bone screws and polymethylmethacrylate (PMMA)
bridges, interbody or intervertebral cement plugs, modified
K-wire spacers with bone screws and PMMA bridge, metallic
plates (stainless still and titanium), plastic plates with
unicortical and bicortical screws, and metallic plates with
locking screws. Early implant failures with loss of distraction
before fusion have been the most common cause of failure in
distraction-stabilization techniques. Common complications
include interspace collapse because ventral or dorsal
migration of the graft, penetration of bicortical pins or screws
into the vertebral canal with spinal cord damage or transverse
foramen with vertebral arteries or nerve root compromise,
fracture of bone cement bridges, pins, screws and plates, and
various soft tissue complications such as esophageal erosion
because of ventral hardware or PMMA prominence. These
disastrous complications have caused some surgeons to rely
only on direct ventral decompression for both static and
traction-responsive lesions. Many authors using either direct or
indirect decompression claim 70 - 90% success rate.
Domino lesion: Recurrence of clinical signs secondary to a
"domino" lesion may occur as a late postoperative
complication with any of these techniques. Recurrence can be
caused by compression at the original site or by a domino
lesion at an adjacent site. Domino lesions or adjacent segment
disease are believed to be the result, at least in part, of
abnormal stresses imposed on one intervertebral space by
fixation of an interspace adjacent to it. These stresses can
exacerbate any pre-existing subclinical instability, and produce
either disc extrusion or hypertrophy of annular or ligamentous
structures. Recurrence of paraparesis to tetraparesis occurs in
up to one third of dogs after either ventral decompression or
metal implant and bone cement fixation. It usually occurs
between six months and four years after the original surgery,
with a mean recurrence of around two years. A recent
meta-analysis examining surgically treated DAWS dogs found
an 80% short term success rate with about 20% of successful
surgeries having significant recurrence after long term
follow-up. The type of surgery performed (decompression
versus distraction fusion), did not influence outcome. Given the
high rate of surgical failure and long term recurrence, new
methods are continually investigated for the treatment of
DAWS in dogs.
Cervical arthroplasty: Ventral decompression and
placement of artificial disc.
The goals of cervical arthroplasty is to preserve motion after
neural decompression while providing distraction and stability.
Ventral slot followed by the implantation of a cervical disc
prosthesis in dogs with DAWS, has the potential to achieve the
optimal goal of spinal decompression, restoration of the
biomechanics at the surgical treated sites with sparing the
adjacent vertebral motor units from the alterations in loading
associated with ventral slot and distraction-fusion surgical
techniques, which may eventually prevent the occurrence of a
domino lesion. Additionally, advantages of cervical arthroplasty
over the standard ventral slot is that the artificial disc acts as a
spacer preventing the early collapse of the vertebral space
usually associated with ventral slot and/or vertebral subluxation
at the treated site. Advantages of artificial disc implantation over
pins or screws and PMMA distraction fixation techniques is the
elimination of the potential complication associated with pin
impingement on neurovascular structures.
In a preliminary in vitro study in dogs (Adamo et al. Veterinary
Surgery 2007) it was concluded that cervical spine specimens
with the implanted prosthesis have biomechanical behaviors
more similar to an intact spine compared to spinal specimens
treated with ventral slot and PMMA procedures. In a recent
clinical pilot study (Adamo et al. Annual ACVIM Forum, Montreal,
CA, 2009), for the first time an artificial disc in Titanium was
implanted in two dogs clinically affected by DAWS. The artificial
disc used was specifically designed and manufactured for the
dog's cervical spine. The artificial disc used in this study is
relatively easy to implant, it is cost-effective (its cost may be
equivalent to the cost of the pins and PMMA), it does not require
special instrumentation, and it could be applied to multiple sites if
needed. In both dogs a good distraction at the treated site was
achieved at the time of surgery, the implant was well tolerated
and there were no signs of implant infection on the serial
post-operatively radiographs. Both dogs had an excellent short
and long term clinical outcome. It is likely that even in the event
of loosing mobility at the treated site after the application of
cervical prosthesis, this prosthesis may still be valuable because
it may act as an internal vertebral distractor, while allowing to the
rest of the spine to slowly and gradually accommodate to the new
dynamic until a final stabilization occurs over time. Maintenance
of distraction after direct spinal compression immediately and
effectively relieves the mechanical compression caused by the
redundant dorsal annulus and/or ligamentum flavum. The
cervical prosthesis provide immediate distraction at the treated
site which further decreased any residual compression from the
redundant ligaments structures, and relieved spinal cord
ischemia caused by compression of the vertebral spinal artery.
The reopening of the narrowed intervertebral foramina further
decompress the nerve roots, eliminating recurrent cervical pain.
One dog was re-assessed with MRI 18 months post-surgery. In
this dog all remaining cervical discs showed no signs of
degeneration, and overall the MRI showed no significant changes
relative to the MRI at the time of diagnosis. The possibility of
performing MRI studies after implantation of this prosthesis,
without interfering with spinal cord visibility, is an advantage over
any other distraction stabilization techniques reported at this time.
This allows, in the event of a recurrence of clinical signs, an
accurate re-evaluation of the spinal cord at the same site as wells
as at adjacent locations, for an early detection of domino lesion
or any other spinal cord diseases. This preliminary clinical study
proved the principle that cervical disc prosthesis in dogs could be
a valuable method to treat DAWS in dogs.
Conclusions
Disc associated Wobbler syndrome is a relatively common cause
of chronic spinal cord compression in adult large breed dogs
including Rottweilers. This disease can be very challenging, both
for the referring veterinarians and even for the specialists. DAWS
is considered a surgical disease but the ideal surgical procedures
still doesn't exist. Further studies are needed to improve the
outcome of this devastating disease in dogs.
Canine artificial disc project for DAWS - Donations
Because of the large scale shortage in research funding, private
donations at this time are the main way to make progress in this
field. We are looking forward to make a significant progress in the
treatment of this devastating disease in dogs and even small
donations can make a significative difference. Contribution can be
made by either contacting directly Dr. Adamo at
[email protected] or by sending a check to the order of Bay
Area VNC, 208 Santa Clara Way, San Mateo - CA 94403, specifying
that the donation is for the canine artificial disc project. Thank you
in advance for your generous contribution.
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